Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures while providing incontinent care to a female resident with neuromuscular bladder dysfunction, a history of stroke, and diabetes. The resident, who had moderately impaired cognition and required assistance with multiple activities of daily living, was observed receiving care during which the CNA wiped the resident's front and back areas without changing gloves or performing hand hygiene. The CNA then handled clean items, including a brief, barrier cream, linen, and a gown, all while wearing the same contaminated gloves. Hand hygiene was only performed after leaving the resident's room and removing the gloves. Interviews with the CNA revealed a lack of awareness regarding the missed hand hygiene and glove change, despite acknowledging the risk of cross-contamination. The Director of Nursing (DON) and the Administrator both stated that staff are expected to change gloves and perform hand hygiene between dirty and clean tasks, and that training on these procedures is provided at least annually. Facility policies reviewed indicated that hand hygiene is required after contact with body fluids, soiled linens, and before and after personal care or toileting, but these procedures were not followed during the observed incident.